Systematic review of alternative access for cardiac catheterization and percutaneous coronary intervention: Dorsal distal radial and ulnar artery catheterization

Complications Following Ulnar Artery Catheterization for Coronary Angiography

BACKGROUND

Use of radial and ulnar access has increased due to its perceived benefits over femoral access. Ulnar artery catheterization can place patients at risk of significant complications, including pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve injury, and critical hand ischemia. The purpose of this study was to describe complications specific to ulnar artery catheterization.

METHODS

After obtaining institutional review board approval, a retrospective review was performed on all patients who underwent ulnar artery catheterization at our institution between 2019 and 2021. Complications were assessed, and complication rates were compared with previously published studies on ulnar artery catheterization for coronary angiography (percutaneous coronary intervention).

RESULTS

A total of 41 patients were available for review with a mean age of 59 years. Of these, 17 patients (41%) sustained complications in the immediate postprocedural period. These complications included hematoma (12 patients, 29%), pseudoaneurysm (1 patient, 2%), ulnar artery thrombosis (1 patient, 2%), ulnar neuropathy (3 patients, 7%), arterial damage requiring repair (2 patients, 5%), transient ischemia (3 patients, 7%), and compartment syndrome (2 patients, 5%). Three of these patients (7%) required operative intervention, and several were admitted to the hospital for an additional period of observation.

CONCLUSIONS

This series highlights the significant risks associated with ulnar artery catheterization for percutaneous procedures. Complications include pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve damage, and critical hand ischemia. Several of these patients required urgent or emergent surgical intervention, with some patients experiencing ongoing ulnar nerve symptoms.

Ultrasound-guided distal transradial access for cardiac catheterization: Technical notes for the interventionalist

Over the latest years, the use of distal radial access (dTRA), also called "snuffbox," has become more and more popular for cardiac catheterization. Indeed, dTRA has several advantages compared to the traditional proximal radial approach, such as a lower risk of hand ischemia, radial artery occlusion (RAO) and faster post-procedural hemostasis. However, due to the presence of different muscular-skeletal structures, as well as to the small diameter of the distal radial artery (dRA), an ultrasound-guided cannulation would be preferred since a blind puncture increases the risk of tendon damage and/or the irritation of the underlying periosteum. The present article is aimed to provide the key tips for performing US-guided access using the dRA in patients undergoing percutaneous cardiac procedures.

Prevalence and predictors of difficult vascular anatomy in forearm artery access for coronary angiography and PCI

Transradial access has established as preferred access for cardiac catheterization. Difficult vascular anatomy (DVA) is a noticeable threat to procedural success. We retrospectively analyzed 1397 consecutive cardiac catheterizations to estimate prevalence and identify predictors of DVA. In the subclavian-innominate-aortic-region (SIAR), DVA was causing failure in 2.4% during right-sided vs. 0.7% in left-sided forearm-artery-access (FAA) attempts (χ² = 5.1, p = 0.023). Independent predictors were advanced age [odds ratio (OR) 1.44 per 10-year increase, 95% confidence interval (CI) 1.15 to 1.80, p = 0.001] and right FAA (OR 2.52, 95% CI 1.72 to 3.69, p < 0.001). In the radial-ulnar-brachial region (RUBR), DVA was causing failure in 2.5% during right-sided vs. 1.7% in left-sided FAA (χ² = 0.77, p = 0.38). Independent predictors were age (OR 1.28 per 10-year increase, 95% CI 1.01 to 1.61, p = 0.04), lower height (OR 1.56 per 10-cm decrease, 95% CI 1.13 to 2.15, p = 0.008) and left FAA (OR 2.15, 95% CI 1.45 to 3.18, p < 0.001). Bilateral DVA was causing procedural failure in 0.9% of patients. The prevalence of bilateral DVA was rare. Predictors in SIAR were right FAA and advanced age and in RUBR, left FAA, advanced age and lower height. Gender, arterial hypertension, body mass, STEMI and smoking were not associated with DVA.

Distal snuffbox versus conventional radial artery access: An updated systematic review and meta-analysis

BACKGROUND

A comprehensive comparison of available data in terms of vascular complications between distal and conventional transradial access is still partial and a net benefit of such approach has not yet been clearly demonstrated.

OBJECTIVE

To provide an updated comparison of complications between distal and conventional transradial access used to perform coronary angiography and/or percutaneous coronary intervention performing a systematic review and meta-analysis.

DATA SOURCES

Data were obtained searching MEDLINE, Scopus, and Web of Science for all investigations published any time to December 22, 2020 reporting a comparison between distal and conventional transradial access. The occurrence of radial artery occlusion was chosen as the primary outcome while the hematoma at access site and spasm as secondary and tertiary outcome, respectively.

STUDY ELIGIBILITY CRITERIA

Case-control studies comparing distal and conventional transradial access for coronary angiography and/or percutaneous coronary intervention. All studies included adult patients aged at least 18 years.

STUDY APPRAISAL AND SYNTHESIS METHODS

Overall, 7073 patients (mean age 57.9 and 58.4 years for distal and conventional transradial access, respectively), were analyzed. The rate of radial artery occlusion was significantly lower in the distal compared with the conventional group (2.1% vs 4.6%, p < 0.001). The pooled analysis, based on a fixed effect model confirmed a lower relative risk of occlusion when distal access is used (RR: 0.46, 95% CI: 0.31-069, p = 0.002, I² = 0%). Conversely, no differences in the risk of developing a hematoma at the access site or in the occurrence of a radial artery spasms were observed comparing the two groups (RR: 0.65, 95% CI: 0.37-1.13, p = 0.12, I² = 0% and RR: 0.88, 95% CI: 0.48-1.63, p = 0.001, I² = 0%, respectively).

LIMITATIONS

Only eight case-control studies met inclusion criteria.

CONCLUSION

This metanalysis confirmed a lower risk of radial artery occlusion using distal access and comparable performance in terms of hematoma, and radial artery spam risk.

Outcomes of transulnar and transradial percutaneous coronary intervention using ultrasound guided access in patients selected based on an ultrasound algorithm

We performed a prospective observational study of 215 patients (58 ± 11 years) and compared the outcomes of ultrasound guided ulnar (n = 98, 45.6%) vs. radial (n = 117, 54.4%) cardiac catheterization and percutaneous coronary intervention (PCI) in patients selected by an ultrasound based algorithm. Primary endpoints included the number of access attempts and conversion to femoral access. Secondary endpoints included all-cause mortality, cardiac mortality, myocardial infarction, stroke, repeat revascularization, stent thrombosis, in-stent restenosis, and access site complications. No significant difference was found in the primary endpoints between radial or ulnar. Ulnar access showed no significant hematomas. Therefore, ulnar PCI is a feasible alternative.

Outcomes of Dorsal Distal Radial, Radial, and Ulnar Artery Percutaneous Coronary Intervention With Ultrasound Guidance in Acute Myocardial Infarction

Ultrasound utilization during access enables precise vessel cannulation. We sought to evaluate the outcomes of ultrasound guided dorsal distal radial artery (DDRA), radial, and ulnar cardiac catheterization (CC) and percutaneous coronary intervention (PCI). We performed a prospective observational study of 224 patients (58 ± 12 years) at an academic medical center from October 2016 to March 2020 (median follow-up of 13 months) and compared the outcomes of ultrasound guided DDRA, ulnar, or radial artery CC and PCI. Groups were divided into DDRA (n = 18, 8.0%), ulnar (n = 94, 42.0%) and radial access (n = 112, 50.0%). Primary endpoints included the number of access attempts and conversion to femoral access. Secondary endpoints included all-cause mortality, cardiac mortality, acute myocardial infarction (AMI), stroke, repeat revascularization, stent thrombosis, in-stent restenosis, and access site complications. In the primary endpoints, no significant difference was found amongst groups in the number of access attempts (P = 0.272) or conversion to femoral access (P = 0.381). In the radial group (59 ± 11 years, median follow-up of 16 months), 2 cardiac mortalities (1 lymphocytic myocarditis, 1 AMI) and 2 noncardiac mortalities occurred. None of the secondary endpoints occurred in the DDRA (66 ± 17 years, median follow-up of 13 months) or ulnar group (56 ± 11 years, median follow-up of 14 months). DDRA and ulnar PCI was safe and efficacious with no complications. Femoral conversion or the number of access attempts was not different between DDRA, ulnar, or radial. Therefore, DDRA and ulnar are viable alternatives for PCI, which can preserve radial for future use.

Use of the left radial artery as vascular access for coronary angiography and as a bypass conduit: A clinical dilemma?

PURPOSE

International coronary revascularization guidelines recommend both, transradial vascular access for coronary angiography/intervention and use of the radial artery as a conduit for coronary artery bypass grafting (CABG). These recommendations may pose a clinical dilemma, as transradial access exposes these arteries to vascular trauma which makes them potentially unsuitable as future grafts. In this study, we investigated the awareness and views of cardiologists on these guideline recommendations.

METHODS

We performed semi-structured interviews with 50 cardiologists from 19 centers, who regularly perform coronary angiographies or interventions, and outlined clinical scenarios to evaluate their preference of vascular access. In addition, we assessed whether preference was related to sub-specialization.

RESULTS

The interviewed cardiologists had 16 ± 9.3 years of professional experience. There were 23 (46%) cardiologists from 7 centers without percutaneous coronary intervention facilities, and 27 (56%) cardiologists from 12 interventional centers. All 50 (100%) cardiologists indicated familiarity with the guidelines, yet 28 (56%) said not to be familiar with the aforementioned dilemma, and 9 (18%) stated there was no dilemma at all. Responses did not differ significantly between interventional (n = 28) and non-interventional (n = 22) cardiologists; however, if the right radial artery was unavailable (e.g., occluded), interventional cardiologists more often said to prefer access via the left radial artery (18/28 (64%) vs. 5/22 (23%), p = 0.001).

CONCLUSION

More than half of the interviewed cardiologists indicated that they had not realized that left transradial access preceding CABG may preclude later use of this artery as a conduit. Notably, in case of unavailability of the right radial artery, interventional cardiologists preferred left transradial access more often than non-interventional cardiologists.

Comparison of Clinical Value between Right Distal Radial Artery Access and Right Radial Artery Access in Patients Undergoing Coronary Angiography or Percutaneous Coronary Intervention

Objective: To compare the feasibility and safety between right distal radial artery access and right radial artery access in patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI).Methods: On the basis of arterial access, 113 patients who underwent CAG or PCI in Kunshan Hospital of Traditional Chinese Medicine between January and October 2018 were divided into two groups: a right distal radial artery group (52 patients) and a right radial artery group (61 patients). We collected general information, the number of puncture attempts, access times, postoperative compression time, and complications.Results: The general characteristics, rate of successful radial artery puncture, and rate of successful catheter placement in the two groups were not different. The right radial artery group had fewer puncture attempts (1.26±0.44 times vs. 2.19±0.53 times, P=0.001) and a shorter access time (3.23±0.86 min vs. 4.77±1.49 min, P=0.001) than the right distal radial artery group. However, the postoperative compression time in the right distal radial artery group was shorter (3.44±0.9 h vs. 7.16±1.21 h, P=0.001). Two cases of bleeding, four cases of hematoma, and one case of artery occlusion in the right radial artery group and one case of hematoma in the right distal artery group occurred before discharge. The rate of total complications in the right distal radial artery group was lower than in the right radial artery group (1.93% vs. 11.48%, P=0.048).Conclusion: CAG or PCI through the right distal radial artery is feasible and safe.